This guide was produced in 2007 to summarise the 10 most important ways in which clinicians can assist the process of clinical coding. Each is based on the basic principles behind coding clear, accurate information about all diagnoses and procedures in order to produce a true picture of hospital activity.This guide was developed through a clinical coding project conducted across Wales, England and Scotland to examine the potential use of hospital activity data to support consultant appraisal.
- Write clearly and legibly in the notes and on discharge documentation, using black ink only. Make sure the patient is identified on every sheet of paper used in the notes.
- Sign, date and time every entry in the notes. Print your name and position at the end of every entry.
- Never remove notes from the hospital. If you need to take notes away from the ward or clinic for an audit or a meeting, always let administrative staff know, and return them immediately afterwards.
- Always communicate any transfers of care to ward administrative staff. This includes when patients go for an investigation or a procedure performed by another clinical team.
- Clearly record details of all the diagnoses (including co-morbidities) and procedures (including those done on the ward) in the notes. Write the main diagnosis first. Best practice is to summarise all of these as the last (discharge) entry in the notes – this will make your discharge summaries easier too. For injuries, note the cause; for overdoses, note the drug; and for infections, note the organism.
- Ask a senior member of the medical staff to confirm or validate these diagnoses and procedures. This can be done when writing in the notes on the discharge ward round.
- Include the details of all diagnoses and procedures on discharge summaries and TTOs (preliminary discharge summaries). Don’t let your discharge summaries pile up on a shelf for weeks on end, awaiting dictation –coding staff have strict deadlines to meet and delays cause huge problems.
- If a clear diagnosis has not been reached, make sure you detail the main symptoms in the notes or discharge summary. Any ‘query’ diagnoses, or diagnoses preceded by a ‘?’ cannot be coded by clinical coding staff. If histology is awaited for a definitive diagnosis, note this down.
- Avoid the use of new or ambiguous abbreviations (eg ‘M.S.’ could mean multiple sclerosis or mitral stenosis). Remember: clinical coding staff are not allowed to make any clinical inferences.
- If your hospital has a standard proforma for admissions or discharge, use it! Fill in all the details it asks for.